Gaceta sanitaria最新文献

Objective: To describe the frequency of discontinuation of pharmacological treatment among older adults due to cost and to analyze inequalities according to demographic and socioeconomic factors.

Method: Retrospective longitudinal study using data from the Mexican Health and Aging Study 2015, 2018, and 2021. A descriptive analysis and multiyear multiple logistic regression were performed to identify demographic and socioeconomic factors associated with treatment discontinuation due to out-of-pocket cost.

Results: Paying for prescribed medications is common in Mexico (2015: 46.1%; 2018: 46.9%; 2021: 53.2%, considering the total sample), and the amount paid was associated (p <0.001) with treatment discontinuation, which tended to decrease over the period (2015: 11.5%; 2018: 11.6%; 2021: 9.5%), but unequally across socioeconomic level (higher among the poorest), sex (more frequent in women), and type of insurance (higher among older adults without social security or with private insurance). In 2018, educational level and place of residence were associated with treatment discontinuation (more frequent in those with lower education and in rural populations).

Conclusions: Out-of-pocket spending on prescribed medications is common among older adults in Mexico and is associated with treatment discontinuation. Poverty and sex are linked to greater vulnerability to discontinuation, exacerbated by the segmentation of the health system.

This essay examines the structural barriers that have hindered the development of a truly universal health system in Mexico. Drawing on a critical review of the design of the health system and the most relevant reforms in recent decades, it examines the effects of social inequality, segmentation, and institutional fragmentation, as well as the setbacks generated by recent reforms such as the Institute of Health for Well-being (INSABI), and the transition to Mexican Social Security Institute for Welfare (IMSS-BIENESTAR). The essay argues that progress towards universal health coverage has been fragile and vulnerable to political shifts. It concludes that addressing these challenges requires a deep institutional transformation grounded in citizenship-based eligibility, solidarity financing, and strong national stewardship. Building a truly universal health system is essential to advancing toward a more just and egalitarian society.

Objective: To analyse the individual and country-level determinants of the use of healthcare systems by populations over 50 years of age in Europe.

Method: We conducted a cross-sectional study using data from Wave 7 (2017) of the Survey of Health, Ageing, and Retirement in Europe. The analysis included 27 countries. We fitted multilevel mixed-effects logistic regression models with hospitalization and doctor visits per person per year as dependent variables.

Results: The findings suggest that country-level variables explain between 3.3% and 4.9% of the differences in the likelihood of hospitalizations and approximately 10% of the likelihood of visiting a doctor at least once a year. Life expectancy and number of beds were the country-level variables most strongly associated with a reduced probability of hospitalization and doctor visits, respectively. The study also found that comorbidity and employment status were risk factors associated with hospitalization and doctor visits, while physical activity was a protective factor.

Conclusions: Country-level factors positively associated with higher health service use are the number of beds, health expenditure per capita and preventable mortality. Life expectancy and treatable mortality are negatively associated with the use of these services. Greater comorbidity increase the likelihood of hospitalization and medical visits, while higher muscular strength or regular physical activity reduce them.

Objective: To estimate the impact of a more equitable pharmaceutical co-payment system by eliminating the distinction between active workers and pensioners, using only personal income as an adjustment parameter, defining more detailed income brackets, and introducing protective limits on personal expenditure.

Method: Data from a random sample of 4,505,483 individuals residing in Spain were used, matching pharmaceutical consumption information from the Ministry of Health with economic data from the Tax Agency. Five microsimulation scenarios were designed, modifying co-payment percentages and monthly limits, and the effects on public pharmaceutical spending, the economic burden between patients and the Spanish National Health System, and the redistribution of the burden among patient groups were evaluated. The Kakwani index was used to measure the progressivity of each scenario.

Results: The results show that equalizing active workers and pensioners and introducing more detailed income brackets can increase the progressivity of the co-payment system. In scenarios 2, 3, 4, and 5, the Kakwani index was higher than 0.2, indicating greater vertical equity. Public budgetary costs ranged from 48 million euros to 710.2 million euros. In all scenarios, the user's share of pharmaceutical expenditure decreased, especially for lower-income groups.

Conclusions: A more progressive and equitable pharmaceutical co-payment system is feasible and can better protect low-income individuals without disproportionate budgetary impact. Eliminating the distinction between active workers and pensioners and exempting co-payments for incomes below 6,000 euros can significantly increase the system's equity.

Objective: To analyze the cost of implementing a population-based lung cancer screening program using low-dose radiation computed tomography (CT) in a high-risk population in Spain.

Method: A budget impact analysis (5 years) was performed from the National Health System' perspective, comparing 16 hypothetical scenarios with screening, based on different age ranges and screening frequencies (annual/biennial), with the current scenario without a lung cancer screening program. Diagnosis, treatment and follow-up costs were considered, as well as the screening costs in the hypothetical scenarios (measured in Euros 2024). From the resident population (50-80 years), the target population and the CT scanners needed to cover the program's demand were calculated. A one-way deterministic sensitivity analysis was performed.

Results: The gross budget impact was estimated at €1708.19 million for the current scenario. Among the hypothetical scenarios, it can range from €3737.17 million (biennial screening, 55-65 years) to €10 009.54 million (annual screening, 50-80 years), resulting in a net budget impact of €2028.98-€8301.35 million. By acquiring 100% of the necessary scanners, the investment reached approximately 22% of the annual program's own costs in the first year. The net impact could be reduced to €1858-€7519 million, for 0% acquisition.

Conclusions: Implementing a lung cancer screening program would generate a high cost for the Spanish National Health System, amounting more than one billion Euros compared to the scenario without screening.

Objective: To design a linear points system to prioritize patients on the waiting list for a general surgery service.

Method: Using a mixed technique (nominal groups and pretesting), criteria and levels for the prioritization system were selected based on the preferences expressed by surgeons and patients in a general surgery service. A subset of the possible combinations of criteria and levels was evaluated by two samples of general population (n=474) and surgical professionals (n=20), through a ranking exercise. The model coefficients (system scores) were estimated using ordered logistic regression. A second sample from the general population (n=120) was used to validate the points system.

Results: A linear points system was developed with five criteria or attributes, each with two or three levels. The scores, calculated as averages from the samples, assigned significant importance to clinical aspects (e.g., risk of deterioration while waiting), but also considered patients' quality of life (pain/discomfort and limitations in daily activities), as well as social criteria (work-related limitations).

Conclusions: Prioritization systems help improve equity in access to healthcare and can contribute to reducing waiting times. Considering social criteria, alongside strictly clinical ones, aligns with the World Health Organization's definition of health.

Objective: To review several behavioral economics-based interventions ("healthy nudges") aimed at mitigating the overuse and underuse of healthcare resources -phenomena associated with poorer health outcomes and increased costs.

Method: A comparative case study approach is used to assess the effectiveness of ten studies designed to improve treatment adherence and prevent underuse, as well as those focused on improving prescribing practices to address overuse.

Results: First, healthy nudges are generally effective, although there is considerable variability in their outcomes. Effectiveness compared to the control group ranges from 5% to over 30%. Second, similar strategies may yield divergent results depending on the context (e.g., medication adherence vs. vaccination uptake). Third, the effect of healthy nudges appears to diminish after the intervention ends, especially for economic incentives. However, default options seem to remain persistent over time.

Conclusions: The article examines the pros and cons of healthy nudges in the use and provision of healthcare services. The evidence gathered from the selected studies suggests that nudges may help rationalize healthcare use. However, challenges remain, such as ensuring the long-term persistence of effects and evaluating their impact on well-being and cost-effectiveness.

Objective: To explore and describe the experiences of home help aides in their work of caring for people with Alzheimer's disease, identifying their perception of the personal factors that influence it.

Method: A qualitative study with a phenomenological-descriptive approach was conducted. Giorgi's method was applied to analyze the experiences of 15 home care assistants who had cared for people with Alzheimer's disease for more than 1 year. Participants were selected using snowball sampling, and data were collected through semi-structured interviews until descriptive sufficiency was achieved.

Results: Four main categories and eleven subcategories were identified, focusing on how they perceive working conditions, the variety of emotions that arise, the skills and competencies needed to provide quality care, and the personal development that the work brings to these professionals.

Conclusions: Home health aides play an essential role in the care of people with Alzheimer's disease, but their working conditions and lack of adequate professional support hinder their performance and well-being. Guaranteeing them decent working conditions and tools to manage their emotional burden will be a key measure to improve the quality of the care they provide.

Objective: After expiry of the patent, price competition can lead to savings. However, in Spain, competition in the retail price of prescription off-patent medicines in pharmacies is rare, while large discounts are negotiated in the wholesale market. Some countries have moved from "competition by discount" to "competition by price". This article compares retail prices in Spain with other countries, and the factors that promote price competition.

Method: This article reviews the literature comparing prices and the factors influencing competition. A detailed analysis of the design of the market was conducted for Spain and Sweden. Interviews were conducted with experts. The systems were compared for the definition of exchange groups, prescription and substitution, how retail prices and profit margins are regulated, and safeguards to avoid risk of shortages.

Results: Depending on sample and methodology, prices in Spain may be on average 51% to 109% greater than Sweden. Broadly, the literature recommends that the off-patent market should be regulated by competitive forces rather than price caps. Spain and Sweden have many features in common. Key differences are: 1) Sweden allows price differences between medicines, and for prices to rise as well as fall, 2) the tendering process, 3) patient choice, and 4) the architecture of the exchange groups CONCLUSIONS: In Spain, first generic or biosimilar entry provokes a 25-40% discount, but thereafter prices are static. In Sweden, price competition is dynamic. This includes, within limits, freedom to set prices, product differentiation, and patient choice.